The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
THE PEARL OF DOWNERS GROVE
DOWNERS GROVE, IL · Medicare-certified · 145 beds
Needs attention
For-profitChain member
Data as of July 1, 2026
1 of 5 overall
1 of 5 stars overall. The facility has a 1-star staffing rating, reported nurse staffing below the federal benchmark (3.60 vs 4.1 hours per resident/day), $30,794 in fines in the last 24 months, and a recent federal penalty; health inspection and quality measures are both 2 stars.
Facility ratings
Health inspections
Staffing
3.5959 hrs/resident/day
Quality measures
Last inspection: May 17, 2026Penalties, last 24 months: $30,794recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.5959.
Staffing detail
- Registered nurses
- 0.82
- Licensed practical nurses
- 0.72
- Nurse aides
- 2.06
- Weekend nursing
- 3.32
Hours per resident per day.
Total staff turnover: 65%
Registered nurse turnover: 65%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
35.9%33.9%Improving
Residents with a fall causing major injury
3%1.3%Improving
Residents with pressure ulcers (bedsores)
8.9%7.3%Improving
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
3.8%5.7%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
18.9%5.9%Improving
Residents whose ability to walk got worse
25.5%8.8%Improving
Long-stay residents on antianxiety or sleep medication
7%8.2%Worsening
Short-stay residents newly given an antipsychotic
2.2%5.6%Worsening
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
35.8%31.5%Improving
Residents with depressive symptoms
42.1%97.1%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—97.4%—
Long-stay residents given the pneumonia vaccine
97%69.6%Worsening
Short-stay residents given the seasonal flu vaccine
—80.4%—
Short-stay residents given the pneumonia vaccine
56.5%2.6%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to notify the resident and family in time before a transfer or discharge, including their right to appeal. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 623 — 42 CFR §483.15 — S/S: F
The home failed to tell residents or their representatives in writing how long their bed would be held after a hospital transfer or therapeutic leave. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 625 — 42 CFR §483.15 — S/S: F
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $30,794 was recorded.
- INSPECTION
Health inspection found 19 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $30,794 in total fines.
- $30,794
Federal fine
Apr 14, 2025
Operator & ownership
Recent ownership change · Apr 10, 2025
Now operated by The Pearl of Downers Grove, previously Downers Grove Rehab & Nursing.
- Ownership
- For profit - Corporation
- Chain
- Part of PEARL HEALTHCARE · 15 homes · 2.7 stars avg
- Occupancy
- 92.9 residents on an average day (64% of 145 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 37 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.